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Abdominal aortic graft infections (AGIs) occur in 1-5% of aortic prosthetic placements. It can result in limb amputation, pseudo-aneurysm formation, septic emboli, aorto-enteric fistulae, septic shock and death. The most frequently involved pathogens are methicillin-susceptible Staphylococcus aureus, methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococci, followed by Enterobacteriaceae and uncommon bacteria. In case of gut involvement the presence of fungi has to be considered. Computed tomography angiography is actually the gold standard diagnostic imaging but magnetic resonance is a valid alternative. Nuclear medicine imaging is commonly used to improve sensitivity and specificity. Signs and symptoms are often aspecific and blood cultures can be negative, requiring alternative ways to detect the microorganism responsible for infection, such as 16S rRNA gene sequencing and molecular rapid diagnostic tests. Curative surgical intervention is the first choice approach, with in-situ reconstruction providing by far the best outcome and xenopericardial bovine patch as a promising option. For patients unable to undergo major surgery, the outcome of conservative approach remains uncertain but usually provides for life-long suppressive therapy. However, in selected cases an attempt of stopping antibiotic treatment after 3-6 months can be done. Given the difficulty in their management, we performed a review of AGIs, in order to raise awareness on clinical presentation, current available diagnostic tools, prophylaxis, surgical and anti-infective treatment of AGIs., (Copyright © 2019 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Traumatic injury to limb peripheral nerves represents an important cause of morbidity and disability. Timely diagnosis and treatment are crucial to optimizing outcomes. The initial evaluation requires a careful history, a thorough physical examination, and electrodiagnostic tests, which lead in most cases to a diagnostic suspicion, but fail to provide an extensive qualitative and quantitative assessment of the nerve damage. Ultrasonography (US) is a low-cost, non-invasive technique which allows for direct visualization of nerve internal structure. It enables performing dynamic examinations and nerves can be followed over long distances in a limb in relatively short times, adding paramount information to extensively characterize the specific type of lesion, and to plan the appropriate treatment. Magnetic resonance imaging (MRI) is complementary to US, especially in examining deep-seated and proximal nerve segments, but is expensive, not available in all institutions and less accepted by patients. The purpose of this review is to describe the role of ultrasonography in the setting of traumatic injury to peripheral nerves, analyzing the main US features in specific types of trauma. Technical aspects with key considerations for optimization are discussed. A brief comparative evaluation between US and MRI is also provided.

Electrolyte alterations and extra-renal disorders are quite frequent in patients undergoing haemodialysis or peritoneal dialysis. The native kidneys may be the site of important pathologies in patients undergoing dialysis, especially in the form of acquired renal cystic disease with frequent malignant transformation. Renal neoplasms represents an important complication of haemodialysis-associated acquired cystic kidney disease and imaging surveillance is suggested. Extra-renal complications include renal osteodistrophy, brown tumours, and thoracic and cardiovascular complications. Other important fields in which imaging techniques may provide important informations are arteriovenous fistula and graft complications. Teaching points • Renal neoplasms represent a dreaded complication of haemodialysis.• In renal osteodystrophy bone resorption typically manifests along the middle phalanges.• Brown tumours are well-defined lytic lesions radiographically, possibly causing bone expansion.• Vascular calcifications are very common in patients undergoing haemodialysis.• Principal complications of the AV fistula consist of thrombosis, aneurysms and pseudoaneurysms.

Introduction: Gallbladder cancer (GBC) is the fifth most common neoplasm of the gastrointestinal tract and the most common cancer of the biliary tract. GBC is suspected preoperatively in only 30-40% of patients. The other 60-70% are discovered incidentally (IGBC) by the pathologist on a gallbladder specimen following cholecystectomy for benign diseases such as polyps, gallstones, and cholecystitis., Materials and Methods: Between 1995 and 2011, 30 cases of GBC, who underwent resection with curative intent in our institutions, were retrospectively reviewed. They were analyzed for demographic data, and type of operation, surgical morbidity and mortality, histopathological classification, and survival. Incidental GBC was compared with suspected or preoperatively diagnosed GBC. Overall survival, disease-free survival (DFS) and the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention were analyzed. The authors also present a systematic review to evaluate the role of extended surgery in the treatment of the incidental GBC., Results: GBC was diagnosed in 30 patients, 16 women and 14 men. The M/F ratio was 1:1.14 and the mean age was 69.4 years (range 45-83 years). A preoperative diagnosis was possible only in 14 cases; fourteen of the incidental cases were diagnosed postoperatively after the pathological examination; two were suspected intraoperatively at the opening of the surgical specimen and then confirmed by frozen sections. The ratio between incidental and nonincidental cases was 1, 14/1, with twelve cases discovered after laparoscopic cholecystectomy. Eighty-one per cent of the incidental cases were discovered at an early stage (≤II). The preoperative diagnosis of the 30 patients with GBC was: GBC with liver invasion diagnosed by preoperative CT (nine cases); gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum (one case); porcelain gallbladder (three cases); gallbladder adenoma (four cases); and chronic cholecystolithiasis (thirteen cases). Every case, except one, with a T1b or more advanced invasion underwent IVb + V wedge liver resection and pericholedochic/hepatoduodenal lymphoadenectomy. One patient refused further surgery. Cases with Tis and T1a involvement were treated with cholecystectomy alone. Nine of the sixteen patients with incidental diagnosis reached 5-year DFS (56.25%) and eight of them are recurrence free. Surprisingly, one patient reached 38 mo survival despite a port-site recurrence (the only one in our experience) 2 years after the original surgery requiring further resection. Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5 years DFS (Tables 2 and 3)., Conclusion: Laparoscopic cholecystectomy does not affect survival if implemented properly. Reoperation should have two objectives: R0 resection and clearance of the lymph nodes., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: This study was done to evaluate by direct comparison the image quality of magnetic resonance urography (MRU) and computed tomography urography (CTU) and to assess the diagnostic confidence of the two techniques in detecting urothelial malignancy in patients with haematuria, Materials and Methods: Thirty-five patients with haematuria underwent both CTU and MRU. Two different investigators evaluated calyceal, renal pelvis, ureteral and bladder visibility. Their diagnostic confidence in detecting urothelial malignancy with the two procedures was assessed. A Wilcoxon matched-pairs test was performed to compare results. Inter-reader agreement was calculated by weighted kappa (WK) statistic. Patient history (further examinations, cystoscopy and histological specimens) was considered as reference standard to calculate receiver operating characteristic (ROC) curves of diagnostic confidence., Results: CTU provided better visibility of urothelial structures (p<0.01) and allowed for greater diagnostic confidence (ROC area 0.994 vs. 0.938) than MRU, with a good inter-reader agreement (WK=0.62). Nevertheless, in obstructive patients with impaired excretory function, MRU, thanks to the static-fluid technique, offered better visualisation than CTU., Conclusions: There is a potential role for MRU in urinary tract imaging, but as diagnostic confidence in detecting urothelial malignancy is poorer than in CTU, it might be stareserved for patients at low risk for malignancy and for evaluating obstructed patients.

Objective: The purpose of this study was to investigate whether cystic renal masses are better characterized on thin axial and multiplanar reconstructed MDCT images than on 5-mm images., Materials and Methods: The records of 70 complex cystic renal masses in 59 patients (45 men, 14 women; mean age, 68 +/- 13 years) who underwent 64-MDCT at two medical centers were studied. Twenty-three of the masses were confirmed on the basis of the histologic findings and 47 in 2-4 years of follow-up. Images were reviewed in two sessions by two radiologists with 12 and 2 years of experience. In the first session, 5-mm axial images were analyzed, and in the second, thin axial images and multiplanar reconstructions. To assess intraobserver variability, analysis was repeated after 1 month. Statistical analysis was performed with Wilcoxon's signed rank test, receiver operating characteristic analysis, and weighted kappa statistics., Results: Radiologists 1 and 2 detected thicker cystic walls (p < 0.001, p < 0.005) and septa (p < 0.03, p < 0.05) and fewer septa (p < 0.005, p < 0.002) on 5-mm axial images and assigned significantly different Bosniak categories than they did in analysis of the volume data (p < 0.04, p < 0.05). Variability was reduced in thin axial and multiplanar views. No significant differences were found in characterization of lesions as benign or malignant in review of 5-mm axial images and volume data sets. The areas under the receiver operating characteristic curve were 0.89 for 5-mm images and 0.96 for volume data sets for radiologist 1 and 0.87 and 0.90 for radiologist 2., Conclusion: Analysis of volume data sets is associated with less intraobserver and interobserver variability than review of 5-mm axial images. Wall thickness and the number and thickness of septa may differ, resulting in assignment of different Bosniak categories. Diagnostic performance in characterizing lesions as benign or malignant, however, is not statistically different for the thick and thin images.

Unlabelled: Intra-abdominal infections are a common cause of nosocomial sepsis and are associated with a severe morbility, mortality and sanitary economy implications, especially for decentrated sanitary structures. Mortality due to diffuse suppurative peritonitis (fom 10 to 20%) nowadays continues to be unacceptably high. Patients outcome is significantly influenced by early adequate surgery and/or peritoneal drainage: moreover, even early and adequate empiric antimicrobial therapy influences patients morbidity and mortality. Multiple empirical regimens have been proposed, but rarely supported by reliable randomized-controlled studies. The authors report 201 cases of patients with fever and meaningful peritoneal involvement occurred since August 1999 up to August 2005: 110 cases were conservatively treated, 91 cases were surgically treated. The paper summarizes IDAB (Infection Disease Advisory Board) guidelines inheriting management of intra-abdominal infections: empiric antimicrobial therapy for the most common causes of abdominal infections is proposed for low-mid level risk patients, focusing on antibiotic treatment duration. High risk patients need to be evaluated paying particular attention to timely surgical infection source control., Conclusion: Despite of the progress in antimicrobial agents and intensive care treatment, peritonitis is still one of the most important infectious problems that a surgeon has to face.

Case Report: It has been demonstrated that paraesophageal hiatal hernia surgical repair can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The Authors report a case of strangulated paraesophageal hiatal hernia occurred in a elderly man and treated with open approach. Eighteen months later, follow up has demonstrated the effectiveness of the repair and the total remission of the symptoms. Recurrences after paraesophageal hiatal hernias repair may decrease with usage of mesh in the hiatus; however uniform criteria for this procedure are lacking. After review of the literature inheriting this uncommon pathology, that present about 5% of the hiatal hernias, no conclusions could be drawn regarding the reliability of the laparoscopic procedure and the necessity for an additional antireflux repair. Moreover, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus cases could not be detected., Conclusions: Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies inherent surgery indications and approach.

Unlabelled: Retroperitoneal sarcomas (RS) are a rare group of malignant soft-tissue tumors. They generally grow until they reach large size before becoming symptomatic, often involving surrounding structures., Case Report: The paper reports the case of a particularly large retroperitoneal liposarcoma (diameter: 48 x 44 x 32 cm, weight: 13.500 kg) surgically treated in a 92-year old woman: the patient tolerated the procedure well and was discharged after a short hospitalization. The paper, moreover, focuses on the diagnostic and therapeutic aspects of this tumour. The need for radical surgery to remove the entire mass is certain, even if it is particularly large; furthermore, the patient must be carefully monitored since retroperitoneal recurrence is frequent and must be treated, wherever possible, surgically. After a review of the literature there is an evidence that higher tumor grade, non-liposarcoma histology, advanced stage, incomplete surgical resection, and microscopic infiltration of surgery resection margins were found to be significantly negative prognostic factors., Conclusions: The study underlines the role of liposarcoma surgery management in order to offer the best chance of long-term survival and, especially on elderly patients, a better quality of life.

Introduction: Gastrointestinal stromal tumors are the most frequent (0,5-3%) mesenchymal tumors in the gastrointestinal tract. They probably originate from the interstitial cells of Cajal and are characterized by an anomaly of c-kit receptor, for a stem growth factor, with tyrosine-kinase activity (c-kit). This mutation causes a permanent activation of the receptor and uncontrolled cell growth. These tumors are associated with low survival in cases of advanced or metastatic disease. Imatinib, a tyrosine kinase inhibitor, induces improved survival in these patients., Case Reports: The authors discuss two cases of gastrointestinal stromal tumors surgically treated and also review the pathophysiology, diagnosis difficulties, role of surgery today, and treatment-related outcome of this type of tumors.

Aim of the Study: There are several varieties of bilioenteric fistulae. The vast majority of fistulas result from chronic cholelitiasis disease. Other relatevely common causes are chronic duodenal ulcer disease, previous instrumentation to the biliary system, chronic bowel inflammatory disease, traumatism, infections., Case Report: The case of a 58-year-old patient is reported in whom one of the rare complications of longstanding duodenal ulcer, the cholecystoduodenal fistula, has occurred. Main symptoms were rapid weight loss (20 kg/3 months), abdominal pain, dyspepsia, vomiting. Perivisceral peritonitis developed a tumefaction (diam: 5 cm) involving duodenum, pancreas, biliary tract and gallbladder. That finding closely simulated a neoplasm evaluating it by CT scan, US scan and even in explorative laparotomy: tumefaction was impossible to isolate, so a duodenocefalopancreasectomy was performed.

The pterion is one of the most interesting bone meeting points in craniofacial osteology and its complex morphology derives from the fact that is the contact point of the facial skeletal elements, skull base and calvarium. Knowledge of its peculiar morphology is mandatory for the pterional approach used in microsurgery and surgery. The Authors studied 506 adult, human skulls where the pterion was accurately reconstructed on polyethylene sheets. They report their data on the morphological analysis and classify the forms. They focussed their attention on the presence of wormian bones at the level of the sphenoparietal suture, on the peculiar existing morphology and reviewed the literature on these classifications. The Authors also evaluated the length of the sphenoparietal suture, the minimum gap between the frontal and temporal, the influence of pteric bones on pterion variability and any correlations between measurements and cranial indexes.